HISTORIA CLINICA Cirugia

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HISTORIA CLINICA

I. ANAMNESIS
Datos de Filiacin:

Nombre y Ap.:________________________________________________

Fecha de Nacimiento:_____________________________

Lugar de Nacimiento:_____________________________

Edad:________________

Sexo:________________

Grado de Instruccin:___________________

Profesin u Ocupacin:__________________________________

Estado Civil:__________________________

Domicilio:____________________ Localidad:_______________

Telfono:__________________ D.N.I:_______________

Fecha de Ingreso:________________________________

II. MOTIVO DE CONSULTA


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II.1 HISTORIA ACTUAL DE LA ENFREMEDAD

Tiempo de la Enfermedad:_____________________________

Forma de Inicio:____________________________________

Curso de la Enfermedad:______________________________

II.2 SIGNOS Y SINTOMAS DE LA ENFERMEDAD


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II.3 RELATO DE LA ENFERMEDAD


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III. ANTECEDENTES PERSONALES
Alergias __________________________________________

III.1

ANTECEDENTES GINECOOBSTETRICOS

Menarqua:________________________

Rgimen Coterminal:_________________

Menopausia:_______________________

Formula Obsttrica:

III.2

ANTECEDENTES PATOLOGICOS

Enfermedades Sistmicas:______________________
Enfermedades Sanguneas:_____________________

IV. EXAMEN CLINICO

IV.1

Examen Fsico General:

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IV.1.1

Ectoscopia:

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IV.1.2

Signos Vitales

Pulso:_____________________
Presin Arterial:___________________

IV.2
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EXAMEN FISICO REGIONAL


EXOBUCAL

Crneo:
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Cara:
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ENDOBUCAL

Enca:
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Piezas Dentarias (generalidades):


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V. EXAMENES AUXILIARES

V.1

Exmenes de Laboratorio:

V.1.1

Tiempo de Sangra:_____________________

V.1.2

Tiempo de Coagulacin:__________________

V.1.3 Tiempo de Protrombina:__________________


V.1.4 Glucemia:________________________

V.2 Exmenes Rx:


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VI. DIAGNOSTICO

VI.1

Diagnostico Presuntivo:

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VI.2

Diagnostico Definitivo:

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VII. PRONOSTICO:
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VIII. PLAN DE TRATAMIENTO:
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IX. EPICRISIS

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Fecha:
__/__/___

Firma:

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